TexanPlus® HMO and HMO-POS Plans Referral/Authorization Program Guide (Houston) This authorization guide applies to contract providers in the following networks: Heritage Physician Networks Pinnacle Physician Management Organization Houston Direct Senior Care IPA Katy Area Health Provider Network Village Family Practice Montgomery Harris Area Physicians

No Authorization Required Facility ER Admissions

Providers Specialty Level Authorization Rules* Primary Care Physicians (PCPs) Capped Specialists

Service Level Authorization Rules* Services Rendered in a Facility Setting Medicare Preventive Services Allergy Injections/Serum & Testing Spirometry Sutures Barium Enemas Bone Density Dopplers (except Nuclear Dopplers) Echocardiograms EKGs Eye Glasses or Contacts after Cataract Surgery Refractions Well Woman Visits Y0067_PR_HMOAuthGrid_0214_IA 02/21/2014

Authorization Required Inpatient Admissions Outpatient services that do not include an ER admission

Cardiovascular Surgeons Plastic Surgeons Electophysiologists

Neurosurgeons Pain Management Plastic Surgeons

Non-Emergent Ambulance Chiropractic Services Chemotherapy, including Drugs PT/OT/ST, Physical Medicine & Rehabilitation Services Cataract Surgery EMGs/Nerve Conduction Studies Colonoscopies Endoscopies Depo-Provera Dialysis Dietician/Nutrionalist Services Holter Monitors Home Health HMO_HMO-POSAuthGrid_TP_Houston

Service Level Authorization Rules* Hospice Care Immunizations & Vaccines Intravenous Pyelograms (IVPs) Lab work Screening Mammograms Pulmonary Function Tests Regular Flat Xrays Treadmill Stress Tests (Cardiac Testing) Ultrasounds unrelated to OB Upper GIs Pacemaker Checks E&M Codes

DME Hyerbaric Treatments MRIs CT Scans Nuclear Medicine Hyalgan Injection and Synvisc Injection PET Scans Sleep Studies Wound Care Infertility OB Ultrasounds

*For specialities and services not defined above: Procedures with billed amounts less than $200 do not require an authorization. Procedures with billed amounts greater than or equal to $200 do require an authorization. NOTES: • Network specialists are able to refer to additional network specialists without the PCP’s intervention, as long as the member’s diagnosis remains the same. The referring specialist would need to complete an authorization form and receive an authorization number. If the member’s diagnosis changes, the PCP will need to begin the referral process. In addition, providers should verify the member’s benefits with the respective health plan. • If additional procedures need to be included under an authorization, the specialist is able to request the additions directly from Care Coordination. • If the time limits of an authorization need to be extended, the referring provider should contact Care Coordination (use the Provider Services phone number provided below). • Referrals for members with chronic conditions can be extended beyond the normal 60-day limit upon request by the specialist; continued verification of eligibility is the responsibility of the requesting provider. For questions, call TexanPlus® HMO or TexanPlus HMO-POS® Provider Services at 1-800-230-2513.

TexanPlus® HMO and HMO-POS Plans Referral/Authorization Program Guide (Houston) This authorization guide applies to contract providers with Memorial Clinical Associates.

No Authorization Required Facility ER Admissions

Providers Specialty Level Authorization Rules* Primary Care Physicians (PCPs) Capped Specialists

Service Level Authorization Rules* Services Rendered in a Facility Setting Medicare Preventive Services Allergy Injections/Serum & Testing Bone Density Spirometry Sutures EKGs Eye Glasses or Contacts after Cataract Surgery Refractions Well Woman Visits Hospice Care Intravenous Pyelograms (IVPs) Immunizations & Vaccines Screening Mammograms Pulmonary Function Tests Regular Flat Xrays Pacemaker Checks Y0067_PR_HMOAuthGrid_0214_IA 02/21/2014

Authorization Required Inpatient Admissions Outpatient services that do not include an ER admission

Cardiovascular Surgeons Colon & Rectal Surgeons Electophysiologists

Neurosurgeons Pain Management Plastic Surgeons

Non-Emergent Ambulance Barium Enemas Chiropractic Services Chemotherapy, including Drugs PT/OT/ST, Physical Medicine & Rehabilitation Services Cataract Surgery EMGs/Nerve Conduction Studies Colonoscopies Endoscopies Depo-Provera Dialysis Dietician/Nutrionalist services Dopplers (except Nuclear Dopplers) Echocardiograms Holter Monitors Home Health DME HMO_HMO-POSAuthGrid_TP_MCA

Service Level Authorization Rules* Lab Work

Hyerbaric Treatments MRIs CT Scans Nuclear Medicine Hyalgan Injection and Synvisc Injection PET Scans Treadmill Stress Tests (Cardiac B17Testing) Ultrasounds unrelated to OB Upper GIs Sleep Studies Wound Care E&M Codes Infertility

*All services not listed above require an authorization. NOTES: • Network specialists are able to refer to additional network specialists without the PCP’s intervention, as long as the member’s diagnosis remains the same. The referring specialist would need to complete an authorization form and receive an authorization number. If the member’s diagnosis changes, the PCP will need to begin the referral process. In addition, providers should verify the member’s benefits with the respective health plan. • If additional procedures need to be included under an authorization, the specialist is able to request the additions directly from Care Coordination. • If the time limits of an authorization need to be extended, the referring provider should contact Care Coordination (use the Provider Services phone number provided below). • Referrals for members with chronic conditions can be extended beyond the normal 60-day limit upon request by the specialist; continued verification of eligibility is the responsibility of the requesting provider. For questions, call TexanPlus® HMO or TexanPlus HMO-POS® Provider Services at 1-800-230-2513.

TexanPlus® HMO and HMO-POS Plans Referral/Authorization Program Guide (GTPA) This authorization guide applies to contract providers with the Golden Triangle Physician Alliance.

No Authorization Required Facility ER Admissions

Providers Specialty Level Authorization Rules* Primary Care Physicians (PCPs) Capped Specialists

Service Level Authorization Rules* Services Rendered in a Facility Setting Medicare Preventive Services Allergy Injections/Serum & Testing Spirometry Sutures Barium Enemas Dopplers (except Nuclear Dopplers) Echocardiograms EKGs Refractions Well Woman Visits Hospice Care Immunizations & Vaccines Screening Mammograms Pulmonary Function Tests Regular Flat Xrays Treadmill Stress Tests (Cardiac Testing) Y0067_PR_HMOAuthGrid_0214_IA 02/21/2014

Authorization Required Inpatient Admissions Outpatient services that do not include an ER admission

Cardiovascular Surgeons Colon & Rectal Surgeons Electophysiologists

Neurosurgeons Pain Management Plastic Surgeons

Non-Emergent Ambulance Chiropractic Services Chemotherapy, including Drugs PT/OT/ST, Physical Medicine & Rehab services Bone Density Eye Glasses or Contacts after Cataract Surgery Intravenous Pyelograms (IVPs) Pulmonary Function Tests Treadmill Stress Tests (cardiac testing) Upper GIs Pacemaker Checks Cataract Surgery EMGs/Nerve Conduction Studies Colonoscopies Endoscopies Depo-Provera Dialysis HMO_HMO-POSAuthGrid_TP_GTPA

Service Level Authorization Rules* Ultrasounds unrelated to OB E&M Codes

Dietician/Nutrionalist services Holter Monitors Home Health DME Hyerbaric Treatments MRIs CT scans Nuclear Medicine Hyalgan Injection and Synvisc Injection PET Scans Sleep Studies Wound Care

*For specialities and services not defined above: Procedures with billed amounts less than $200 do not require an authorization. Procedures with billed amounts greater than or equal to $200 do require an authorization. NOTES: • Network specialists are able to refer to additional network specialists without the PCP’s intervention, as long as the member’s diagnosis remains the same. The referring specialist would need to complete an authorization form and receive an authorization number. If the member’s diagnosis changes, the PCP will need to begin the referral process. In addition, providers should verify the member’s benefits with the respective health plan. • If additional procedures need to be included under an authorization, the specialist is able to request the additions directly from Care Coordination. • If the time limits of an authorization need to be extended, the referring provider should contact Care Coordination (use the Provider Services phone number provided below). • Referrals for members with chronic conditions can be extended beyond the normal 60-day limit upon request by the specialist; continued verification of eligibility is the responsibility of the requesting provider. For questions, call TexanPlus® HMO or TexanPlus HMO-POS® Provider Services at 1-800-230-2513.